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Cognitive and Behavioral Practice 15 (2008) 317324 www.elsevier.com/locate/cabp

A Self-Help Handout for Benzodiazepine Discontinuation Using Cognitive Behavioral Therapy

Mariyam Ahmed, Henny A. Westra, York University Sherry H. Stewart, Dalhousie University
Although prescription rates may be declining, benzodiazepines (BZs) are still very commonly prescribed for the treatment of anxiety disorders. Because many anxiety patients require assistance in successfully discontinuing BZs, cognitive behavioral therapy (CBT) approaches have been specifically developed to target this issue, and an evidence base now exists to support their use in this manner. In this paper, we first provide the rationale for why BZ discontinuation is desirable. We then present a self-help handout that we have used productively in our cognitive-behavioral practice to assist patients in deciding whether they are ready to attempt discontinuation of their BZs, and to prepare them with strategies for successful discontinuation. The clinical use of this handout is discussed and suggestions offered for integrating it effectively into CBT for anxiety.

prescription rates may be declining in view of alternative, less problematic pharmacotherapies, benzodiazepines (BZs) are still commonly used for the treatment of anxiety disorders (Boixet, Batlle, & Bolibar, 1996; Bruce et al., 2003). For example, recent population level data from Statistics Canada suggest that nearly 20k of individuals with a current anxiety disorder are taking BZs (Beck et al., 2005). Moreover, 50k of patients presenting for anxiety disorders treatment are already on BZs, with many unable to discontinue (Romach, Busto, Somer, Kaplan, & Sellers, 1995). Despite known difficulties with the use of BZs, they continue to be sanctioned by general physicians (Boixet et al., 1996; Mant, Mattick, de Burgh, Donnelly, & Hall, 1995) and psychiatrists (Balter, Ban, & Uhlenhuth, 1993; Uhlenhuth, Balter, Ban, & Yang, 1995) for long-term use in clinical anxiety management. Despite the continued widespread use of BZs for treatment of anxiety, research suggests several reasons for patients to consider discontinuation. BZ use has been associated with cognitive problems, dampens benefit from exposure-based treatments for anxiety disorders, and can be addictive (Michelini, Cassano, Frarre, & Perugi, 1996; Westra, Stewart, & Conrad, 2002). Other reasons for BZ discontinuation include limited long-term efficacy in anxiety management and patient preference for nonpharmacological treatments for anxiety (Banken & Wilson, 1992; Otto, Pollack, & Sabatino, 1996).
LTHOUGH

Given that there is a withdrawal syndrome associated with BZ discontinuation (which can be serious), and most chronic BZ users have had one or more unsuccessful discontinuation efforts (Romach et al., 1995), patients require assistance in successfully discontinuing these medications (Otto, Hong, & Safren, 2002). The intent of this paper is to offer a patient self-help handout that can be used to facilitate successful BZ discontinuation (see Appendix A). The impetus to create the handout was based on observation in clinical practice of frequent and reoccurring concerns expressed by clients in the context of BZ discontinuation. As well, there was a need to integrate management of these common concerns with basic psychoeducation from research on BZ discontinuation (e.g., common withdrawal symptoms, appropriate taper schedule). To contextualize BZ discontinuation, we offer a brief elaboration of the reasons for considering such a course of action, particularly in the context of clients presenting for cognitive behavioral therapy (CBT).

Reasons for Considering Discontinuation

Addiction BZ discontinuation has received increased attention as a result of high rates of unsuccessful discontinuation attempts and the severity of discontinuation-related symptoms among anxiety disorder patients (Otto et al., 2002). For instance, rebound panic attacks are common in discontinuation of BZs in panic disorder (Fyer et al., 1987) and the withdrawal symptoms of BZs mimic somatic symptoms of anxiety (e.g., shakiness, agitation, tension; Roy-Byrne & Hommer, 1988). In fact, anxiety symptoms experienced with BZ discontinuation are reported to be

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Ahmed et al. equally or more severe than those experienced prior to BZ treatment (Noyes, Garvey, Cook, & Suelzer, 1991; Rickels, Schweizer, Case, & Greenblatt, 1990). Among chronic BZ users, the reported incidence of withdrawal symptoms on discontinuation is estimated at between 40k and 100k (Rickels et al., 1990). In this regard, Otto, Pollack, Meltzer-Brody, and Rosenbaum (1992) have developed a conceptual model for BZ discontinuation in anxiety. They have proposed that, despite the effectiveness of BZs in providing a partial or full blockade of panic attacks, a fear of the physical sensations associated with panic still persists (Otto & ReillyHarrington, 1999). In fact, in a naturalistic study of BZ users with anxiety disorders, Stewart, Westra, Thompson, and Conrad (2000) reported greater selective attention to physical threat cues compared to those not using BZs, supporting the continued vigilance to bodily threat sensations in BZ users. These fears may be increased upon an attempt to discontinue BZs since withdrawal symptoms mimic the anxiety for which BZ use was initiated. Moreover, Stewart et al. (2000) also found an association between selective attention to threat and asneeded or p.r.n. use of BZs, suggesting that this type of use in particular may be problematic for individuals with anxiety. Otto and colleagues (Otto et al., 2002; Otto et al., 1992) have proposed that an effective treatment for BZ discontinuation must (a) decrease conditioned fears of somatic sensations and the tendency to catastrophically misinterpret these sensations; (b) provide patients with coping skills for managing the severity of anxiety sensations; and (c) provide patients with skills for minimizing withdrawal symptoms. Several discontinuation studies provide support for the model and suggest that brief CBT can be used as an aid to BZ discontinuation (Hegel, Ravaris, & Ahles, 1994; see also Otto & Reilly-Harrington, 1999, for a review). Thus, although simultaneous BZ use may interfere with the efficacy of CBT in treating anxiety disorders (see review by Westra and Stewart, 1998), ironically, the one place where CBT may be particularly beneficial for anxiety patients taking BZs is in helping patients discontinue their use of BZs. For example, Bruce, Spiegel, and Hegel (1999) have demonstrated that upon CBT-assisted discontinuation of alprazolam, panic disorder patients maintained treatment effects and were abstinent from further medication use at 2to 5-year follow-up. Moreover, a reduction in Anxiety Sensitivity Index score was a significant predictor of BZ discontinuation success. Similarly, it has been suggested that CBT interventions are likely to be effective in assisting antidepressant discontinuation (Schmidt et al., 2002). Selective serotonin reuptake inhibitors (SSRIs) are often recommended as a pharmacological treatment for anxiety disorders (American Psychiatric Association, 1998; Coplan, Pine, Papp, & Gorman, 1996). However, upon tapering or discontinuation of SSRIs, patients report increased anxiety symptoms (Coupland, Bell, & Potokar, 1996; Rickels, Schweizer, Weiss & Zavodnick, 1993). At least one study (Whittal, Otto, & Hong, 2001) found support for the effectiveness of CBT in assisting patients to discontinue SSRI treatment for panic disorder and agoraphobia (PDA). Interference With CBT CBT is recommended as a first-line treatment for anxiety (Evans, Bradwejn, & Dunn, 2000; National Institute for Clinical Excellence, 2004). Curran (1991) suggests that progress in CBT might be hindered by simultaneous BZ use due to CBT's emphasis on episodic learning, which is weakened with BZ use. Controlled investigations of anxiety disorder treatment outcome comparing CBT with and without concomitant BZ use suggest a superiority of CBT alone and a general failure of these treatments to operate in a complementary fashion in the treatment of anxiety (Marks et al., 1993; also see Otto, Smits, & Reese, 2005, for review). Several cognitive factors associated with BZ use (e.g., reduced self-efficacy, heightened selective attention to threat cues) have been suggested as potential explanations for such treatment noncomplementarity (for a review see Westra & Stewart, 1998). For example, memory impairments might be one mechanism involved in poorer CBT performance observed in individuals with anxiety disorders concurrently utilizing BZs. CBT places heavy emphasis on learning and integration of new experiences. It is possible that new information acquired in session or between sessions (e.g., during exposure exercises) might be less well-remembered by individuals taking BZs compared to nonmedicated individuals. This might lead to poorer integration of new information for challenging catastrophic beliefs. Consistent with this hypothesis, Westra & colleagues (2004) have demonstrated that BZ-medicated patients with panic disorder, in comparison with their unmedicated counterparts, show poorer recall of psychoeducational material presented in the clinical setting during CBT (Westra et al., 2004). In addition, as-needed use of BZs might be particularly detrimental to positive CBT outcomes compared with regularly scheduled use. BZs are often used on an asneeded or p.r.n. basis among anxiety patients (Romach et al., 1991) and are frequently prescribed for use on an asneeded basis by prescribers (Westra and Stewart, 2002). Among the most common reasons stated for p.r.n. use is facilitation of exposure to feared situations, reduction of general anxiety, and inhibiting impending panic attacks. Despite the intuitive appeal of such uses to produce anxiety reduction, the treatment benefits of such practices are generally not supported by empirical data, which find increased anxiety with p.r.n. use (for a review, see Rachman,

A Self-Help Handout for Benzodiazepine Discontinuation 1984; Woody & Rachman, 1994). It has been suggested, for example, that p.r.n. use of BZs may lead to reduced opportunities for exposure to feared physical sensations in panic (Westra & Stewart, 1998). In this regard, in a naturalistic study of a heterogeneous group of anxiety patients, p.r.n. use of BZs for coping with anxiety symptoms was found to be a significant negative predictor of degree of change in both anxiety sensitivity and anxious arousal from pre- to post-CBT (Westra et al., 2002). Cognitive Problems BZs have been associated with significant episodic memory impairments, such as anterograde amnesia (for reviews see Buffett-Jerrott & Stewart, 2002). That is, individuals who are administered BZs remember subsequently presented information less well compared to individuals who are administered placebo. Also, BZinduced impairments in explicit memory (i.e., conscious, effortful recall) and possibly implict memory (i.e., memory without conscious awareness) as well have been demonstrated in controlled experimental studies with several types of BZs (Bishop, Curran, & Lader, 1996; Buffett-Jerrott, Stewart, Bird, & Teehan, 1998). Several factors appear to have an influence on the degree of memory impairments, such as type of BZ (e.g., Curren & Gorenstein, 1993), dose (e.g., Weingartner, Hommer, Lister, Thompson, & Wolkowitz, 1992), and the time of memory encoding following BZ administration (Buffett-Jerrott, Stewart, & Teehan, 1998; Stewart, Rioux, Connolly, Dunphy, & Teehan, 1996). In general, higher dosage and higher potency BZs exert greater memory impairments (Legrand et al., 1995). Memory impairments do not appear to be subject to tolerance with repeated BZ use, are not secondary to other effects such as sedation, and seem to be maximal at peak drug-blood concentrations (Curran, 1991). Patient Preference Research on treatment preference for mental health problems indicates that in comparison to medication, anxiety patients and potential patients strongly prefer psychotherapy (Banken & Wilson, 1992; Deacon & Abramowitz, 2005). Surveys of patients with mental health problems, as well as individuals who hypothetically chose a preferred treatment if they were to suffer with anxiety, indicate a preference for psychotherapy over medication (Dwight-Johnson, Sherbourne, Liao, & Wells, 2000; Walker, Vincent, Furer, Cox, & Kjernisted, 2000). The strength of this preference is consistently impressive, ranging from 67k (Dwight-Johnson et al., 2000) to 87k (Zoellner, Feeny, Cochran, & Pruitt, 2003) of patients preferring psychotherapy across studies. These studies also reveal that pharmacotherapy is chosen by very few individuals as a first choice for treatment for mental health problems. As such, assistance with BZ discontinuation may be welcomed by many individuals who prefer nonpharmacological intervention.

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Overview of the Self-Help Handout for BZ Discontinuation

The intended use of the handout in Appendix A is in the context of CBT, for patients who are attempting or wish to discontinue BZs for any anxiety disorder. As with any medication treatment, the patient is strongly encouraged to consult their prescriber/physician prior to discontinuation. In our experience, most patients presenting for CBT concomitantly using BZs have a desire to discontinue their use of BZs in favor of alternative, self-management anxiety control strategies. Similar to the recommendations of Otto et al. (2002), this can typically best be done after the patient has acquired some anxiety management skills in the context of CBT. We also recommend that as a preliminary step to taper, that the patient stop using BZs on a p.r.n. or asneeded basis. This can be done even at the beginning of CBT and prior to the acquisition of other anxiety management skills. A move to more regular use, at the same dose and frequency of use, may begin to break the contingency between BZ use and management of feared situations or body sensations. Finally, it is desirable that the patient have a score in the nonclinical range on the Anxiety Sensitive Index (ASI; Peterson & Reiss, 1992) before beginning to taper BZs. The ASI is a widely used instrument that assesses fear of anxiety-related physical and cognitive sensations due to beliefs that these sensations have catastrophic consequences. ASI scores are among the best predictors of successful BZ discontinuation (Bruce, Spiegel, Gregg, & Nuzzarello, 1995). This handout provides a list of questions for individuals to determine their readiness for tapering BZs. Also, it presents general guidelines for implementing BZ reduction and discusses expected symptoms associated with tapering of BZs. Finally, it suggests coping strategies to manage and challenge common worries related to BZ reduction. Patient feedback on this handout has been extremely positive (and one of the reasons we wished to make it available for wider clinician use). The process we have successfully used in working with this handout is to introduce it in the context of a broader discussion with the client of the possibility of BZ discontinuation. It may be introduced after someone has already decided to reduce BZs or, alternatively, as an educational tool in those considering reducing BZ use. Used in the latter manner, the handout can provide valuable information useful for continued discussion of the pros and cons of discontinuing BZs. In either case, we go over the handout with clients during sessions, asking them to respond to each of the breadiness for discontinuationQ questions and elaborating and discussing their concerns as necessary. For

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Ahmed et al. example, if the client has a high ASI score, we would explain the rationale for why a score in the nonclinical range is important to successful discontinuation. Then we would suggest interoceptive exposure exercises as a way of minimizing fearful reactions to body sensations that will occur upon later withdrawal of BZs. Going over each readiness question also allows the clinician to offer the rationale behind each item (e.g., the necessity of collaboration with other care providers, the importance of avoiding the consequences of sudden elimination of BZ use, etc.). The remainder of the handout is also reviewed in detail, collaboratively with the client, and the client is strongly encouraged to discuss his or her taper decisions and intentions with a physician. The section on bWhat to ExpectQ provides valuable psychoeducational material to shape client expectancies about normal and typical withdrawal symptoms. This avoids common catastrophic misinterpretations of these withdrawal symptoms and reframes them as normal, expected, and even an indication of progress in discontinuing. Finally, the sections on bHow to CopeQ and bChallenging Common Worries in Tapering BenzodiazepinesQ offer multiple suggestions to assist the client and clinician in developing a written plan for alternative responses and coping strategies the client might use to maximize the probability of success in discontinuing BZs. For example, the therapist could ask the client to identify his or her catastrophic beliefs and then identify which alternative strategies most strongly resonate as possibilities for responding to these thoughts. While there may be idiosyncratic catastrophic beliefs about BZ discontinuation that are not represented, the handout contains the most common misinterpretations of these symptoms, based on our clinical experience. Clients gain confidence in being able to successfully discontinue with this collaborative approach to developing an action plan to assist with discontinuation. The plan can then be reviewed, monitored, and adjusted as necessary once the taper begins. The utility of this handout is supported by clinical impression of the handout in routine clinical practice by multiple clinicians. While we do not have empirical data on the efficacy of the handout, the principles are consistent with BZ discontinuation protocols, which have demonstrated efficacy (e.g., Otto, Pollack, & Barlow, 1995). A controlled clinical trial is warranted as a next step in evaluation of this clinical tool as an aid to effective BZ discontinuation for anxiety disorder patients. cation is an anti-anxiety medication (benzodiazepine) I can check the list on the next page. I MUST answer bYesQ to each of these questions before I begin to reduce my medication. I have consulted the doctor who prescribed YES NO the medication to discuss tapering the medication. I have told my psychiatrist, my family YES NO physician, or other doctors involved in my care about my intention to taper. I understand that I MUST NOT stop my anti- YES NO anxiety medication bcold-turkeyQ or all at once. I am prepared to go slowly and gradually in YES NO reducing my anti-anxiety medication. I have an Anxiety Sensitivity Index Score YES NO (ASI)1 of less than 30. I only take my anti-anxiety medications at YES NO regularly scheduled times and DO NOT take them when I feel specific symptoms (e.g., panic attack or heightened anxiety) or am in specific situations (e.g., doing something I am afraid of). I understand that I WILL FEEL anxious as a YES NO necessary part of the withdrawal process. I am prepared to see my increased anxiety as a YES NO normal and necessary part of getting off antianxiety medication. I will NOTinterpret this increased anxiety as a reflection that I cannot cope or that I am relapsing. I have some solid self-help strategies for YES NO dealing with my anxiety when it occurs (e.g., breathing, self-talk, etc.). If I answered bNoQ to any of the above questions, successful reduction of my anti-anxiety medication will be difficult. If I still wish to reduce my medication, I should discuss each of my bNoQ responses with my therapist or doctor. Part B: Identifying If the Medication I Am Taking Is a Benzodiazepine IMPORTANT: The medications that are being considered for reduction are a very specific set of anti-anxiety drugs known as Benzodiazepines. They include drugs on the list below. If the drug I am considering reducing is not

Appendix A. HOW TO: Reduce Anti-Anxiety Medication

Part A: Am I Ready? The following questions will help me to learn whether or not I am ready to taper (slowly reduce) my anti-anxiety medication. If I am not sure if my medi1 ASI refers to the Anxiety Sensitivity Index or bfear of anxiety sensations.Q Scores on this scale are a good predictor of success in discontinuing benzodiazepines. Ask your treating clinician for a copy of this questionnaire.

A Self-Help Handout for Benzodiazepine Discontinuation on the list, I should consult my therapist and physician to discuss this. Drug: Xanax/Niravam Ativan Rivotril/Konopin Serax Valium Librium Halcion Tranxene/Tranxilene Tranxilene Paxipam Dalmane Centrax Doral Restoril Also Known as: Alprazolam Lorazepam Clonazepam Oxazepam Diazepam Chlordiazepoxide Triazolam Clorazepate Clorazepate Halazepam Flurazepam Prazepam Quazepam Temazepam

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3. Go slowly and gradually. A taper schedule should be at a reasonable rate (i.e., a fast taper rate might lead to withdrawal symptoms, yet tapering too slowly might prolong the discontinuation process) and this can be best accomplished in collaboration with a physician. For example, a taper schedule can be designed to reduce the dose by an equal amount each day, with moderate reductions at the higher doses and smaller reductions at lower doses. For instance, a taper schedule for alprazolam might involve a decrease of 0.25 mg every 2 days until at 2 mg/day then, decrease by 0.125 mg every 2 days.2 4. Start reducing at the dose which would be easiest to eliminate. Start reducing at the time of day when I need the medication least. For example, if I feel the least anxious in the evenings, start tapering at that medication taking time. 5. Decide on a taper schedule and stick to it. Decide in advance when and where I will start to reduce and by how much. Stick with the planned reduction. For example, if I decided to take 1/2 pill less in the evening on Saturday this week, do this and stick to it regardless of how that reduction makes me feel. Once I feel reasonably confident that I have handled the first planned reduction, then I can move on to the next planned reduction. 6. DO NOT give in to my withdrawal symptoms by deciding to take the dose I eliminated anyway. Ride out the increased anxiety of withdrawal.
What to Expect.

Part C: General Guidelines Planning the Taper.

Decide whether I really want to discontinue the benzodiazepine medication. Do a cost-benefit analysis of the advantages and disadvantages of getting off medication. Discontinue ONLY if the benefits outweigh the costs.
One benefit might be reducing my long-term risk of relapse. One cost might be increased anxiety while going through withdrawal.

Consult a physician. To discuss the decision to taper, seek their advice, and plan the taper collaboratively with them.

Predict that I will be anxious. This is a normal and expected symptom of withdrawal. Understand that it may take a while before the medication is entirely out of my system. As a general rule, the longer I have been taking benzodiazepines, the longer it will take to get them out of my system. As a general rule, the higher the dose and the more often I have taken benzodiazepines, the longer it will take to get off them. The older I am, the longer it may take for the medication to leave my system.
Expect withdrawal symptoms to start anywhere between 4 hours or up to 10 days.

The following are several guidelines for tapering, but the specifics of the taper plan should be determined in collaboration with your physician.

1. Eliminate bas-neededQ use. Before reducing my medication, make sure I have moved to taking them ONLY on a regularly scheduled basis. That is, DO NOT use them to cope with specific times I feel anxious (e.g., during a panic attack) or a particular anxiety-provoking situation (e.g., doing something I am afraid to do). Use them only according to the time on the clock. 2. Stop carrying my medication around. This could be a first step, even before tapering, to help me be less dependent on the medication and to challenge myself to cope using self-help techniques only.

Remember that the symptoms of Benzodiazepine withdrawal are like anxiety: shakiness (very common), insomnia, morning sweats, fear, agitation,

2 For more detailed help in planning BZ reduction, see Otto et al. (1995).

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Ahmed et al. increased blood pressure and heart rate, nausea, flushing, and dizziness. Test myself: If my dose of medication has not changed since I started taking it, ask myself if my symptoms of anxiety have changed. If the answer to this is, qYes, the symptoms have reduced,q then again this must be due to something else (for example, my own self-help efforts) because the medication is unchanged. Remind myself of tolerance. This refers to the fact that benzodiazepines actually become less and less effective the longer I take them. My body qgets usedq to them and so any reductions in my anxiety symptoms, especially lately, are likely not due to this medication. Ask myself: If the medications were so helpful, why would I need to seek out other anxiety management treatments at all? Ask myself: On how many days since starting the medication have I felt in control of my symptoms? Compare this to the total number of days I have been on the medication. Ask myself: On how many days since starting self-help have I felt in control of my symptoms? Compare this to the total number of days using self-help. Remind myself of the negative aspects of medication, such as the bite it may take out of my self-esteem or sense of control over my feelings. Remind myself that benzodiazepine medication can only control physical feelings of anxiety. It cannot control the more important parts of anxiety, such as how I choose to think (for example, using positive selftalk) and the way I choose to cope in response to anxiety (for example NOT avoiding). Remind myself: As long as I remain on the medication, I will never be 100k certain that my progress is really due to my own self-help efforts. Getting off medication is my brave and courageous way of reinforcing my own coping skills once and for all. I Worry: My anxiety will get worse and I'll relapse. Accept: My anxiety may definitely get worse because that is a NORMAL consequence of withdrawal. In fact, this is a good sign that I am making progress since going through withdrawal is necessary to be free of the medication. Just like an alcoholic must go through detox. Remind myself: The increase in anxiety will be temporary. Short-term pain for long-term gain. Remind myself: Dont confuse having increased anxiety with relapse. Increased anxiety is simply a biological response to the drug being reduced in my body. It says absolutely nothing about my ability to cope or not cope!

People who gradually withdraw have fewer withdrawal symptoms than people who withdraw more quickly.
How to Cope.

Anticipate what I will say to myself and the qthinking trapsq I will fall into. In this way I can prepare in advance of it actually happening. Tips to follow. Treat the increased anxiety I feel as the bBenzodiazepine Flu.Q Just ride out the symptoms: Just like the flu, I simply need to let it pass and make myself as comfortable as I can while ITm letting the withdrawal run its course. Use positive self-talk. Develop a set of positive things I can say to myself to help me get through. For example: bI can beat this,Q bI have handled worse things,Q bI can cope,Q etc. Use distraction. Plan to do something else TEMPORARILY while riding out the withdrawal. Enlist the help of others. Let my family or significant others know my plans to reduce medication. Let them know what help I may need and the changes they may see during the process and once it is over.
Part D: Challenging Common Worries in Tapering Benzodiazepines I Worry: The medication is really responsible for my progress. Test myself: If medication were responsible for improvement in my symptoms, I should expect that the times I was taking the most medication, should be the times I felt the least anxious. Ask myself: In the past, when I was taking the most medication, how bad were my anxiety symptoms? Test myself: If the medication were responsible for my improvement, my symptoms should be out of control at times when I am taking the least medication. Ask myself: In the past, when I was taking the least medication, how bad were my anxiety symptoms? Remind myself: A persons experience is often the exact opposite of what he or she would expect if the medication really worked for long-term symptom control. That is, the times when they were taking high doses of medication were actually the times when their symptoms were the worst. And the times (like perhaps now) when they are taking the least medication, their symptoms are actually under much better control.

If you take any person, put them on the benzodiazepine medication, and then take them off, they will feel anxious. Remind myself: I am actually MORE at risk for my anxiety getting worse in the long-run (i.e., relapse) if I DO NOT withdraw from the medication. Remind myself: Even though my anxiety increases, I will never be back to square one. No one or nothing can remove the knowledge I have gained about managing anxiety.

A Self-Help Handout for Benzodiazepine Discontinuation Remind myself: Medication reduction can only make me physically more anxious, it cannot change my thoughts, or dictate what I will do or how I will cope. It only hits one part of the cycle of anxiety (body symptoms) but I still control the other two more important parts (how I choose to think and how I choose to cope). Remind myself: There are many good reasons to discontinue medication: I am proving to myself that I really can cope with anxiety without medication. I am proving to myself that anxiety may be uncomfortable but it is not dangerous. I want to reduce my risk of relapse even further by getting rid of the medication. I want to reinforce my own ability to be in control of my feelings. Tell myself: Even if I have a panic attack, Ive handled this successfully many times before. In fact, Im an expert at having and managing anxiety. Reframe: See the anxiety as an opportunity to really test out my self-help skills. It is a chance to prove once and for all that I can cope. Remind myself: FEELINGS ARE NOT FACTS! Just because I feel like I am relapsing, doesnt mean I am or will. Test myself: Make a list of all the self-help skills I have used in the past to help me manage my anxiety. Identify the old thinking and acting traps I fall into when I feel physically anxious (for example, bITm dyingQ or bI need to get outQ). Then use all my self-help materials and strategies by making a plan to resist these traps. Remind myself: I am in control of the pace at which I reduce my medication. I can back off and go more slowly if I feel overwhelmed. There is no rush. Test myself: Rate and re-rate my anxiety as I taper the medication. Use a scale of 1 to 100 (1 = completely relaxed and 100 = severely anxious) as a test to see if my anxiety and/or physical symptoms eventually come down with time and with medication reduction. Think into the future. Project how good I will feel after I ride out this bout of withdrawal or even after I get off the medication. Remind myself: IM TAKING CONTROL BACK!
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The second author acknowledges the support of the Canadian Institute of Health Research, New Investigator Award. Address correspondence to Mariyam Ahmed, Department of Psychology, York University, 4700 Keele Street, Behavioral Sciences Building, Toronto, Ontario, Canada M3J 1P3; e-mail: ahmedmar@yorku.ca. Received: December 7, 2006 Accepted: May 2, 2007 Available online 11 July 2008